EMERGENCY DEPARTMENT CLINICAL DECISION UNIT

EMORY UNIVERSITY SCHOOL OF MEDICINE ?

DEPARTMENT OF EMERGENCY MEDICINE

EMERGENCY DEPARTMENT CLINICAL DECISION UNIT

EMORY MIDTOWN HOSPITAL EMORY UNIVERSITY HOSPITAL EMORY SAINT JOSEPH HOSPITAL EMORY JOHNS CREEK HOSPITAL

GRADY MEMORIAL HOSPITAL

2019

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TABLE OF CONTENTS

3/12/2019

EXECUTIVE SUMMARY ................................................................................................4 Contact Information ..........................................................................................

GENERAL GUIDELINES FOR CDU OPERATIONS .............................................................5 Physician accountability..................................................................................... Patient Selection..............................................................................................6 General principles of CDU patient selection........................................................ General EXCLUSIONS from the CDU..................................................................7 Physician CDU Rounding principles: .................................................................8 Patient care flow .............................................................................................9 CDU Rounds................................................................................................... 10 Guidelines for "holds" or "boarders" in the CDU ............................................ 11 CDU Quality Assurance and Utilization Review ............................................... 12 CY 2016 Clinical Decision Unit ? EUH, EUHM, ESJH.......................................... 13 Grady CDU (10/1/2016 ? 9/30/2017): ..............................................................14

GUIDELINES FOR STRESS TESTING OBSERVATION UNIT CHEST PAIN PATIENTS ........... 15 EMORY UNIVERSITY HOSPITAL CDU ........................................................ EMORY UNIVERSITY MIDTOWN HOSPITAL CDU................................... 16 EMORY JOHNS CREEK HOSPITAL..................................................................... GRADY HOSPITAL CDU.......................................................................................

CONDITION SPECIFIC GUIDELINES.............................................................................. 17 ABDOMINAL PAIN.............................................................................................. ALLERGIC REACTION ...................................................................................... 18 ASTHMA ........................................................................................................ 19 ATRIAL FIBRILLATION ? ACUTE ONSET. ........................................................... 20 BACK PAIN ..................................................................................................... 21 CELLULITIS .........................................................................................................22 CHEST PAIN ? POSSIBLE ACS........................................................................... 23 COPD EXACERBATION .................................................................................... 24 DEHYDRATION OR VOMITING /DIARRHEA ..................................................... 25 ELECTROLYTE ABNORMALITY ......................................................................... 26 GASTROINTESTINAL BLEED (UPPER) ............................................................... 27 HEART FAILURE.............................................................................................. 28 HEADACHE..................................................................................................... 29 HEMODIALYSIS ? URGENT* ............................................................................ 30 HYPEREMESIS GRAVIDARUM ......................................................................... 31 HYPERGLYCEMIA / MODERATE DIABETIC KETOACIDOSIS* .............................. 32 HYPOGLYCEMIA ............................................................................................ 34 MINOR TRAUMATIC BRAIN INJURY* .............................................................. 35 PAPILLEDEMA* .............................................................................................. 36 PNEUMONIA.................................................................................................. 37 PSYCHIATRIC / SUBSTANCE ABUSE* ............................................................... 38 PYELONEPHRITIS............................................................................................ 39

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RENAL COLIC.................................................................................................. 40 SEIZURES ....................................................................................................... 41 SOCIAL ADMISSIONS...................................................................................... 42 SYNCOPE ....................................................................................................... 43 TOXICOLOGY OBSERVATION. ......................................................................... 44 TRANSFUSION OF BLOOD AND BLOOD PRODUCTS ......................................... 45 TRANSIENT ISCHEMIC ATTACK (TIA). .............................................................. 46 VAGINAL BLEEDING ....................................................................................... 47 VERTIGO ........................................................................................................ 48 VTE (LOW RISK VENOUS THROMBO EMBOLISM)* .......................................... 49 SUPPLEMENTAL MATERIALS...................................................................................... 51 Observation Policies - CMS................................................................................. Observation Policies: American College of Emergency Physicians (ACEP) ........ 52 Hospital, Stress Test, Location, and Supervision of Patient Condition During Test .... .53 STRESS TEST SELECTIONS BACKGROUND MATERIALS................................................. 54 Hospital specific stress test selection ............................................................. 55

Emory University Hospital CDU........................................................................ Emory Midtown Hospital CDU ? 7/2011 .............................................. 56 Grady Memorial Hospital CDU ? 2/2014.............................................. 57 HEART score ? CDU bed request form ............................................................ 58 Vasodilator stress testing protocol ..................................................................... CDU REGADENOSON (Lexi-scan) PROTOCOL ................................................... 59 EUH CDU Coronary CTA (cCTA) checklist => in sequential order ...................... 60 Mild ? Moderate DKA Flowsheet.................................................................... 61 Minor Traumatic brain injury: Meets BIG 1 criteria (see table) ....................... 62 CIWA ? Ar ?Alcohol Withdrawal Scoring Guidelines Tool ................................ 65 EUHM Fast Track Dialysis

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EXECUTIVE SUMMARY

What: Observation services are provided to selected emergency department patients specifically "to determine the need for inpatient admission", where an inpatient is a patient whose care is expected to cross "two midnights".

Who: Observation patients are usually emergency department patients requiring 6 ? 24 hours of care, with an average length of stay of 15 hours. Of observation patients, 70-90% should be discharged from observation. They are of low severity of illness and limited intensity of service.

Where: Observation services are provided in protocol driven observation units. Emergency department units are called "Clinical Decision Units" (CDU) and are staffed by emergency providers.

Why: There is a growing body of evidence which finds that care of observation patients in a protocol driven observation unit is associated with improved outcomes relative to traditional care. These outcomes include: improved patient and provider satisfaction, less diagnostic uncertainty for high risk conditions, shorter hospital length of stays, comparable or better clinical outcomes, improved hospital flow and resource utilization, and lower costs for patients, hospitals, and payers.

How: Guidelines for common conditions drive protocols (i.e. power plans) and are based on best evidence, local practice, and expert consensus. Each guideline includes: inclusion and exclusion criteria for the CDU, potential interventions in the ED and CDU, and criteria for discharge or admit from the CDU. Physicians are assigned to cover the CDU by shift. They round at the beginning of their shift with APPs and staff to confirm or modify plans and are available as needed 24/7 while working in their respective areas outside of the CDU. Clinical practice, documentation, coding, and billing is based on national guidelines. Utilization and quality measures are followed monthly and used to modify practice. Additional information is provided for operational issues and to describe common conditions, such as chest pain.

Contact Information

Chief of Service - Observation Medicine Michael Ross, MD

Emory University

CDU PHONE: 404-712-2908

Medical Director George Hughes, MD george.hughes@emory.edu Emory Johns Creek University

CDU PHONE: 678-474-5154

Medical Director Michael Ross, MD maross@emory.edu

CLINICAL DECISION UNITS:

Emory University - Midtown

Emory Saint Joseph

CDU PHONE: 404-686-3154

CDU PHONE: 678-843-7770

Medical Director Michael Ross, MD maross@emory.edu

Medical Director Ken Miller, MD ken.miller@

Grady Memorial Hospital

CDU PHONE: 404-616-6448

Medical Director Matthew Wheatley, MD mwheatl@emory.edu

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GENERAL GUIDELINES FOR CDU OPERATIONS

Mission statement ? The observation units strive to provide excellent patient care to those patients needing further management to determine their need for inpatient admission or discharge. The units accomplish this by providing active management of specific conditions using protocols based on the best available clinical evidence. We provide this in a setting which is both efficient for health care providers and pleasant for our patients. We strive for the units to be nationally recognized centers of excellence in patient care, teaching, and research in Observation Medicine. Scope of Observation Unit Services ?

The "Clinical Decision Unit", or CDU, is an emergency department (ED) observation unit which provides physician and hospital "observation services" as defined by the Center for Medicare and Medicaid Services (CMS), the American Medical Associations Current Procedural Terminology Manual (AMA-CPT), and the American College of Emergency Physicians' (ACEP) policy on the management of observation units. The CDU is staffed and managed by the Department of Emergency Medicine.

These units provide services to emergency patients who require care that goes beyond their initial evaluation and management in the emergency department or clinic to determine the need for inpatient admission. The scopes of these services are outlined in this document.

Management ? The CDU is administratively part of the emergency department (ED) and therefore it is under the ED nursing and medical administration.

Nursing Leadership ? The charge nurse for the CDU is supervised by the ED nursing director.

Physician Leadership ? The Chief of Service for Observation Medicine shall provide oversight of Observation Services at Emory (Emory Healthcare and Grady) Observation Units. Each specific CDU shall have a CDU site director who shall work under the direction of the Chief of Service of Observation Medicine. CDU Associate Provider leaders will work under the direction of the CDU site director on CDU issues. Physician coverage is provided 24 hours a day, and 7 days per week as assigned by shift.

Other disciplines: Other health care team members involved in patient care includes, physicians (non-OU), respiratory therapy, pharmacy, dieticians, physical therapy, social workers, laboratory services, environmental services, clergy, utilization review, and other support services.

Physician accountability CDU: The ED PHYSICIAN WILL ACT AS THE "GATEKEEPER" FOR ALL ADMISSIONS TO THE CDU. THE PHYSICIAN ASSIGNED TO COVER THE CDU IS THE "ACCOUNTABLE" PHYSICIAN FOR ALL CDU PATIENTS. This means that admission to and discharge from the unit can only be made by the ED physician (or His or Her designee). Other services may not "bypass" the ED physician and admit directly to the CDU. However, they may admit their patients for observation services to hospital inpatient beds as dictated by hospital policy. Consultants and Private Attending's may recommend discharge or admission to or from the CDU; however, the final disposition order must come from the ED physician.

Associate Providers (NP or PA):

CDU - The CDU associate provider (AP) works under the direct supervision of the ED attending physician assigned to cover the CDU. The AP will facilitate patient care in the CDU as detailed below. Work activities outside the CDU may vary by setting and will occur following completion of CDU activities.

Unit operation - Patients are managed in the OU based on the guidelines detailed in this manual. These guidelines are developed through research and internal consensus. Their goal is to facilitate optimal patient care and consistency. Guidelines detail what is felt to be reasonable care for most patients with the specified condition most

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of the time, with the understanding that appropriate exceptions may occur. Prudent judgment may allow care outside these guidelines. There will be a monthly meeting to review unit utilization, quality, clinical and operational issues ? attended by the OU medical director, AP, and nursing representative.

Unstable patients ?As detailed below, clinically unstable ED patients are excluded from the CDU based on general unit guidelines and condition specific guidelines. If a patient becomes unstable while in the CDU then the patient should be evaluated by the CDU attending physician and / or CDU Associate Provider. Unstable patients should be moved back to the ED for acute stabilization and admission. If a CDU patient experiences a cardiac or respiratory arrest, the staff will notify ED staff immediately (either press the code button in the patient's room which in turn will notify ED staff or place an overhead page to the ED for "Doctor to the CDU STAT").

Patient Selection

Overview

The observation units manage patients for up to 18-24 hours, after which time a disposition should be made. Care

beyond this time frame may occasionally occur if it is clear that as short term disposition is likely to occur (i.e. stress

test in the morning). The goal is to provide accelerated care while decreasing inappropriate ED discharges. Patients

will first have been managed in the ED and found to need further management to determine their need for inpatient

admission or discharge home. If a patient can be discharged within 4-6 hours then placement in the CDU is

discouraged. Based on clinical judgment, and the best scientific evidence, patients should have at least a 70%

probability of discharge within 18 hours - if managed actively. Patients will be managed in the unit using the

guidelines and principles detailed in this document.

In determining the need for inpatient admission, the "2-Midnight Rule" definition of an inpatient will be used. This definition is most consistent with CPT and CMS policies. The 2-Midnight benchmark states that if a physician expects a patient's hospital care to span two midnights then the patient may be admitted as an inpatient. This timeframe starts on hospital arrival (i.e. into the ED). Time in the ED and as an observation patient may count toward the first midnight. If an observation patient cannot be discharged on the second day then inpatient admission should be considered before the third day.

General principles of CDU patient selection

Focused patient care goal - The Physician's note should document the specific reason for admission to the CDU. Generally there should be only one specific problem that requires acute management. When multiple problems require acute management, the likelihood of discharge is much lower. "Focused Goals" fall into three broad categories: ? Diagnostic evaluation of critical symptom ? i.e. chest pain, syncope, etc. ? Short term treatment of an emergency condition ? i.e. asthma, dehydration, etc. ? Management of psychosocial needs ? i.e. need for home support services or placement (if feasible)

Limited intensity of service and severity of illness ? based on available resources, such as nurse to patient ratios, higher acuity patients will need to be placed in the hospital for management. This is defined for each condition for several conditions in this document, however conditions outside this list may be observed if they meet the general principles outlined here.

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General EXCLUSIONS from the CDU

PATIENTS WITH AN INCOMPLETE CHART A missing or poorly documented ED history, physical, and medical decision making, a single concise diagnosis, a clear plan, and appropriate orders. This makes is very difficult to efficiently and safely manage the patient.

HIGH SEVERITY OF ILLNESS Such as patients requiring more nursing care than can be offered in the unit. For example, patients with acutely unstable vital signs, unstable cardiac, pulmonary, or neurological conditions. These patients should be managed in the initial Emergency Center treatment area until deemed to be stable for at least one hour or admitted.

HIGH INTENSITY OF SERVICE Such as patients that are too unstable or ill to be observed. For example difficult intoxicated or suicidal psychiatric patients, patients requiring frequent vital signs or treatments. This includes patients on intravenous vasoactive drip infusions of nitroglycerin, labetalol, Cardizem (diltiazem), dopamine or dobutamine, epoprostenol (flolan), or treprostinil (remodulin). PATIENTS FOR WHOM INPATIENT ADMISSION IS CLEARLY NEEDED If the ED physician identifies the need for a traditional inpatient admission, the patient should not be admitted to the CDU. However, when appropriate, patients that are "holds" may be temporarily boarded in the unit based on criteria below. AGE LESS THAN 15 YEARS OLD Younger patients will be managed in a pediatric CHOA hospital based on general pediatric transfer practices. Pediatric CDU patients over the age of 15 should NOT have significant underlying illness or co-morbidities (such as underlying heart disease, sickle cell disease, etc.) requiring skilled pediatric nursing care. Children in the CDU should have a legally responsible adult stay with them while in the CDU. OBSTETRIC PATIENTS OVER 20 WEEKS PREGNANT These patients should be managed on the Labor and Delivery unit according to hospital and ED practices. If they have already been evaluated and cleared by the obstetric service (either on L & D and sent back to ED, or cleared by an obstetrician) for CDU management of a non-obstetrical condition (i.e. asthma), then they may be managed in the CDU. PATIENTS AT RISK OF SELF HARM Specifically suicidal patients, acutely psychotic patients, or patients with significant inebriation due to alcohol or illicit drugs. As a setting, the observation unit is not physically designed to closely monitor these patients for their safety. Patients determined to be at risk of self-harm should have their clothing held and be moved to the ED for safer psychiatric observation (consistent with ED practices). ANTICIPATED CDU LENGTH OF STAY LESS THAN 4 HOURS OR OVER 24 HOURS The work of transferring, admitting, and discharging patient whose stay is under 4 hours is not the best use of these resources. On the other hand, patients whose care is expected to cross two midnights are more likely to be admitted. Reasons for staying beyond 18 hours should be documented in the chart. Medicare patients whose observation stay exceeds 24 hours will be provided the CMS "MOON" document as outlined by CMS policies and hospital practices. PATIENTS WITH (1) AN ACUTE GAIT DISTURBANCE (2) OVER AGE 65 WITH BACK PAIN, (3) TRANSPLANT PATIENTS (except stable kidney transplants on chest pain protocol), (4) HEMODIALYSIS PATIENTS ON DIFFERENT (non-HD) PROTOCOL These patients have been found to have a very high admit rate and often require more than 24 hours of care.

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Physician CDU Rounding principles: Round at the beginning of each shift - CDU rounds are comparable to having a patient signed out at shift change. At the beginning of a shift get "sign out" from the departing provider, examine the patient, add or change orders, and make dispositions. The compelling question should be "why is this patient still here?" Patients who have not clinically "declared themselves" within 15-18 hours are less likely to leave, so a disposition should be made. Morning rounds are busiest, afternoon are lightest (average census is lowest) and evening rounds may be chart review only unless a patient is likely to be discharged or needs to be seen. 1. Who to round on

Round on all patients that have not had a completed final disposition made. 2. What to do

Review the chart (i.e. ED H/P, transfer of care paperwork, labs, x-ray reports, consults, test results), take report from the CDU nurse / AP, examine the patient (focused on why they are in the CDU), and document / communicate your findings and plan with the CDU team. Discharge / admit patients as needed (with AP if present). 3. CDU (observation) discharge summary The attending physician will provide all four CPT (99217) elements:

a. Clinical course in the unit ? working with CDU staff who will facilitate care b. A final examination (focused) c. Instructions for continuing care - outpatient or inpatient depending on the disposition d. Preparation of discharge (or admission) records ? depending on disposition

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